Unsightly varicose veins may require medical attention

About half of Americans older than 50 have varicose veins -- veins that are swollen and often can be seen bulging beneath the skin. (SHNS graphic by James Hilston / Pittsburgh Post-Gazette)

About half of Americans older than 50 have varicose veins -- veins that are swollen and often can be seen bulging beneath the skin. They often are colored dark purple or blue and found most often on the backs of the calves or the inside of the leg.

For most, varicose veins are chiefly a cosmetic problem. But if they are accompanied by other symptoms, such as leg pain when standing for a prolonged period, swelling of the feet, ankles or legs, itching over the vein or if the skin changes color or gets drier, thinner or develops scales, it could be a sign of a serious ailment.

About 40 percent of women and 25 percent of men in their 50s have varicose veins, and about 70 percent of women and 40 percent of men in their 70s have them.

The job of veins is to return blood to the heart so it can be recirculated. To do this, the veins in the legs have to work against gravity. Muscle contractions in the lower leg act as pumps. Tiny valves in the veins open to send blood to the heart, then close to keep blood from flowing back downward. Varicose veins occur when these valves weaken, causing blood to pool in the legs. The veins appear blue because they contain blood that has released its oxygen.

With age, veins lose elasticity and valves weaken. A tendency to develop varicose veins can run in families. Some people are born with fewer valves in their veins, valves that don't work properly or abnormalities in the vein wall that cause the valves to leak.

"The most important predictor is genetic," said Dr. Ellen Dillavou, director of venous services and vascular surgery at the University of Pittsburgh Medical Center. "On top of genetic, if you have multiple pregnancies, or you have to stand for long periods of time, that can push you closer (to having varicose veins)."

If both parents have varicose veins, "there is almost a 75 percent chance their children will develop them, too," said Dr. Satish Muluk, a vascular surgeon at Allegheny General Hospital in Pittsburgh.

Pregnancy increases the flow of blood in the body but decreases the flow upward from the legs to the pelvis. Pressure is placed on the legs by the child growing in the uterus. The hormones estrogen and progesterone have a relaxation effect, which can weaken vein walls.

People who stand or sit for long periods of time are at greater risk. Those who are overweight and don't exercise increase their risk.

Exercise is important, Dillavou said, because "the veins themselves don't have any muscles in them. The muscles squeeze the veins and push the blood."

The stronger the muscles are, the more effective they are at pumping blood back to the heart. Wearing compression stockings also helps. They squeeze the leg, which reduces the amount of blood in and pressure on the legs. Don't try to choose a pair yourself. You should seek a doctor's help in determining how much pressure should be applied to your leg.

Only about 10 percent of those afflicted seek medical treatment for them. If varicose veins are unsightly only, that's OK. But anyone with symptoms -- especially swelling of the leg, flaking or itching skin, or skin ulcers near the ankle -- should see a doctor. The ulcers, a possibly serious condition, can be caused by fluid leaking into the skin tissue when blood backs up instead of returning to the heart. A coalition of professional groups has prepared a self-assessment test accessible at www.RethinkVaricoseVeins.com.

People have three kinds of veins: superficial veins, which lie close to the skin; deep veins, which lie in groups of muscles; and perforator veins, which connect the superficial to the deep veins.

Varicose veins are a mild form of chronic venous insufficiency (CVI), a condition that occurs when the walls or the valves of veins are not working effectively. In deep veins, CVI can have more serious complications.

Another condition that can cause leg pain -- phlebitis -- is an inflammation of a vein that can lead to a blood clot. It's not considered serious in a superficial vein, but it is potentially more dangerous in a deep vein.

Phlebitis is uncomfortable, but usually not dangerous. More serious is a blood clot in a deep vein, called deep-vein thrombosis. Blocking circulation in the vein is serious enough, causing pain and swelling, but if a portion of the blood clot breaks loose and travels first to the heart and then to the lungs, it can be fatal.

There are new nonsurgical treatments for varicose veins. They work by sealing the diseased vein shut.

Radiofrequency ablation uses heat to contract the collagen in the vein walls, causing them to collapse. Laser ablation heats the blood in the diseased vein, causing it to coagulate and close off the vein.

In sclerotherapy, a chemical is injected into the vein, which causes it to seal. It also is an outpatient procedure, used most often to treat small veins.

The most common types of surgery are vein-stripping (the surgeon ties off the diseased vein from the groin to the calf below the knee, then removes it) and angioplasty and stenting. The surgeon uses a balloon (angioplasty) or a metal-scaffold tube (stent) to hold open the blocked artery. Angioplasty and stenting are used to correct deep-vein problems, Muluk said.

Ablation largely has replaced vein-stripping for treatment of CVI in superficial veins.

"We hardly ever recommend surgery," Dillavou said, "because the minimally invasive treatments work just as well or better."